Oral surgery

2. Examination of Patients in Oral Surgery Clinic

2.1 Maintaining Medical Records

  • Essential for effective treatment and legal protection.

  • Medical records serve as legal documentation in case of disputes.

  • Detailed records help improve treatment quality and track patient care.

2.2 Deontology and Medical Ethics

  • Focus on the moral responsibilities of healthcare professionals.

  • Importance of patient-doctor relationships built on trust and respect.

  • The physician's oath stressing ethical behavior in practice.

2.3 Examination Methods

2.3.1 Basic Methods of Examination

  • Interview: Gathering patient complaints and medical history.

  • Life and Medical History: Previous treatments and co-morbidities.

  • Importance of considering patient’s personal characteristics.

  • Use of printed questionnaires to assist in capturing details.

2.3.2 Objective Examination of the Maxillofacial Region (MFR)

  • External Examination: Includes face and neck inspection.

  • Palpation: Assess soft tissues, organs, and bones.

    • Evaluate mouth opening, TMJ movement, and organ palpation.

2.3.3 Additional Examination Methods

  • Utilized when data from basic methods are insufficient.

  • Types include:

    • Laboratory: Blood tests, microbial analysis.

    • Radiological: X-rays, CT scans for thorough diagnostics.

    • Functional: Assess organ functionality through tests.

2.4 Patient Complaints and Pain Assessment

2.4.1 Types of Pain

  • Characteristics of Pain: Duration, intensity, and nature of pain.

    • Pain can signal various oral ailments such as pulpitis or periodontitis.

    • Pain classification:

      • Permanent vs. Temporary

      • Localized vs. Diffuse

      • Severity: Mild, moderate, severe.

2.4.2 Common Complaints in Oral Surgery

  • Complaints may include:

    • Pain during chewing or biting

    • Bleeding gums or halitosis

    • Swelling or asymmetry in the face area due to inflammation.

2.5 Medical History and Anamnesis

2.5.1 Importance of Medical and Dental Anamnesis

  • Collect detailed information about previous visits and treatments.

  • Ensure awareness of allergic reactions and previous dental experiences.

  • Anamnesis Vitae: Record of general health and hereditary disorders.

  • Social Anamnesis: Consider social factors impacting health.

2.6 General Examination of the Patient

  • Physical observations: BP, pulse, and respiratory rate.

  • Assess general condition of the patient (satisfactory to severe).

    • Satisfactory: Stable vital signs.

    • Moderate to Severe: Needs for urgent care.

2.7 Examination of the Maxillofacial Area

2.7.1 External Inspection

  • Assess face shape, symmetry, and skin condition.

  • Look for signs of infection or lesions (e.g., rashes, swelling).

2.7.2 Palpation Techniques

  • Palpation: Assess consistency, tenderness, and impending issues.

    • Check for lymph nodes and soft tissue changes.

2.7.3 Oral Cavity Examination

  • Evaluate lips, gums, and mucosa for abnormalities.

  • Measure mouth opening degrees to determine motility.

2.8 Additional Diagnostic Methods

2.8.1 Radiological Methods

  • Use X-ray, CT, and MRI for detailed imaging.

    • Intraoral Radiographs: Assess tooth roots and bone quality.

    • Orthopantomography (OPTG): Comprehensive view of jaw anatomy.

2.8.2 Laboratory and Cytological Examination

  • Include clinical blood tests, microbiological analysis, and patient fluids.

  • Analyze tissue for pathology through histological and cytological techniques.

2.8.3 Functional Diagnostic Methods

  • Assess salivary function via sialometry and other diagnostic tests.

  • Utilize ultrasound for soft tissue and lymph node evaluations.

2.9 Patient Medical Documentation

2.9.1 Importance of Outpatient Medical Records

  • Legal necessity: Responsibilities outlined by Form 043/u.

  • Documentation of informed consent and treatment plans.

  • Accuracy in records impacts both patient care and medical liability.

2.9.2 Key Sections of Outpatient Records

  • Include diagnosis, objective data, treatment history, and consultations.

  • Essential details regarding dental health and treatment outcomes.

2.10 Conclusion on Deontology and Medical Ethics

  • Uphold ethical relationships with patients and maintain confidentiality.

  • Importance of continuing education and respectful communication.

  • Be aware of the legal rights and treatment responsibilities in dental practice.